Strong-Hope Referral Form - Salt Lake Behavioral Health

3/18/2015
Dear Military Colleagues:
SLBH has developed the Strong~Hope Military Programs referral and admission process so that there are only 6
Steps from a military referral to admission. The 6 Steps are outlined below. A one page referral form is attached.
1. Call 877-640-0220. All communication is through the Military Care Coordinator until the service member
arrives.
2. Complete the attached Referral Form. Forward to the Military Care Coordinator with the following: Clinical
symptom documentation (psychiatric evaluation, clinical notes, or biopsychosocial), current medication list,
and medical information. Scan and email the packet to [email protected] or Fax (877) 5588846. If you are faxing clinical without an initial call, please call/email to confirm receipt.
3. Acceptance will be made within an hour of receiving written clinical unless there are significant medical
complications requiring a prompt physician review.
4. Call 877-640-0220 to confirm SLBH Military Programs have a bed reserved for the patient and insure travel
arrangements are made to the location.
5. Prior authorize admission through TRICARE.
6. Coordinate travel arrangements with Military Care Coordinator and transport patient. Flight information
(including escort contact if applicable) must be received prior to arrival to ensure ground transportation can be
arranged if requested.
* For Guard and Reserve members, the packet in #2 above must include a copy of active duty orders for 31+
consecutive days of active duty and a copy of the Line of Duty papers.
The command and clinical contacts entered on the referral form will receive a ‘safe arrival’ call from our admissions
team when the service member has safely arrived to the facility. Weekly clinical updates (including discharge
planning once treatment is complete) will begin thereafter between the Strong~Hope treatment team and clinical/
command contacts.
Salt Lake Behavioral Health Location and airport details:
Salt Lake Behavioral Health
3802 South 700 East
Salt Lake City, UT 84106
Tax ID 27-1365684
Salt Lake City International (SLC)
Assistance:
Michael Allison. MA, AMFT
Program Manager
[email protected]
801-633-3308
Kristine Lucas
Military Affairs Specialist
[email protected]
801-597-1967
Dustin Gallegos
Military Care Coordinator
[email protected]
877-640-0220
Strong~Hope Referral Form
18 March 2015
Please complete as much information below as possible. To make a referral to Strong~ Hope, please call 24/7 at 877640-0220. Please complete this form and forward along with patient clinical information to the Military clinical team
via email to [email protected] or fax (877) 558-8846.
Name of referring military professional:
Installation:
Non DSN Phone:
After hour’s emergency number:
Department:
Email:
Patient Information
Patient Name:
SSN:
Diagnosis:
Patient to deploy:
Yes
No
Anticipated deployment date:
Please note any UCMJ actions or discharge plans for this SM:
Patient Cell Phone:
Military occupation:
Current occupation:
DOB:
Patient Duty Station Contact Information:
Duty Station:
:
PLEASE IDENTIFY ONE CLINICAL AND ONE COMMAND CONTACT WHO WILL RECEIVE PROGRESS
UPDATES DURING THE PATIENT STAY. PLEASE IDENTIFY.
Patient Home Fort/Base Command: Command updates are automatic in Freedom Care, please note if you prefer we
do not update command on this case.
International (overseas) bases please include country code and complete numbers to call from the US to you.
Unit Commander Name:
Command:
Non-DSN Phone:
After hour’s emergency number:
E Mail:
Will this patient be discharged to the same unit/installation? Yes
If not, please describe alternate plan:
No
Home Fort/Base Behavioral Health Department:
Primary Clinical Contact Name if different than the referral source:
Department:
NON-DSN Phone:
E Mail:
OTHER CONTACTS WHO MAY BE CONTACTED IF NECESSARY:
Behavioral Health Prescriber Contact Name:
Department:
Non DSN Phone:
E Mail:
PCM Contact Name:
Department:
Non DSN Phone:
E Mail:
A packet from the medical record will be provided at the time of discharge including a handwritten or typewritten
discharge summary. If not included in the packet, the typewritten discharge summary will be faxed within 3 business
days of the discharge. Please provide the name and phone/fax of the person the discharge summary should be sent to:
Name:
Non DSN Phone:
Fax: